Understanding Sleep in Children

By: Dr. Michelle MD

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Sleep is as much a necessary part of normal life as eating and drinking. We cannot function without sleep. Besides resting the body, sleep helps the brain process memories and experiences. When childhood sleep problems arise, everybody suffers – the sleepless child and the sleepless parents and siblings. To understand sleep problems, we need to know the basic facts about sleep.

• Newborns – 4 months: 16-17 hours a day in about seven equal blocks
• 4 – 9 months: 15 hours a day in four or five longer blocks, two thirds of the sleep being at night
• 10 months – 3 years: 12 hours in one block at night, plus two 1-hour daytime naps.
• 3 – 10 years: 12 hours at night, no naps
• Teens: 9 hours (if they get less, they make it up by sleeping long blocks on weekends)
• Adults: 8 to 8¼ hours (now you know why you are chronically tired!)

Sleep is characterized by two different types: Rapid Eye Movement (REM) sleep which is when dreams occur and non-REM sleep which is divided into four stages.

REM sleep is the special sleep when dreams occur. During this phase, the brain is very active, but the body is extremely still. Only the breathing muscles and the eye muscles are really working. We only enter REM sleep at the end of a non-REM cycle, which consists of 4 stages:

Stage I: Drowsy but still able to respond to voices, noises and other stimuli

Stage II: Dozing, falling asleep, but easily aroused. This is the sleep you see at a lecture when people close their eyes and let their heads fall and suddenly wake up as they fight to stay awake.

Stage III: Asleep. All muscles are relaxed and breathing begins to slow.

Stage IV: Deep sleep. In this stage, outside noises would not be noticed and the person is hard to wake up.

At the end of stage IV there is a brief awakening before going on to the next phase.

These stages of sleep occur in cycles throughout the night. The early part of the night, Stages I and II occur repeatedly until the first REM sleep occurs, about two hours after falling asleep. These early REM cycles are very short and last only a few minutes. They are followed by progressive periods of Stage II-IV sleep. As the night goes on, the REMS get longer and longer. REMS can be over 90 minutes in length. Dreams are the most long and intense in the early hours of the morning, just before arising.

Sleep Problems
There are many different aspects of sleep that can be disturbed in childhood. The following is a discussion of the most common sleep problems.

Self-Settling
Self-settling is the ability to get oneself to sleep. Since there are cycles of lighter and deeper sleep all night long, everyone wakes a little, several times a night – to roll over, fix the blanket or even look around to see that everything is OK. If a child is always helped to fall asleep, he will want that help several times a night, whenever he has his natural awakenings at the end of each sleep cycle. If he knows how to fall asleep without assistance, he will do it right away and go back to sleep without crying.

Newborns almost always fall asleep while feeding. After about four months of age, it is best to try to feed the baby before bedtime and put him in the crib while still awake. He then will find some way of helping himself to fall asleep. A cloth diaper or thin blanket, or a small soft toy, can be introduced as a transitional object which will help him fall asleep. Many people find themselves rocking, shaking, rolling the carriage, or allowing the baby to pull on the mother’s wig, ear or finger, or lying in bed with the baby to get the baby to sleep. These are all transitional methods. I really prefer not using these adult dependent methods, since they do not allow the baby to learn to settle himself down.

It is not easy to break a habit, so be prepared to tolerate crying for the first few tries. Self-settling is a skill. During the learning phase, the baby will cry from frustration when you do not give him the transitional method he is accustomed to. After about three nights, he will acquire the skill and he will stop crying when you put him to bed. Dr. Richard Ferber, in his book Solve Your Child’s Sleep Problem, describes a gentle, gradual method for weaning a baby or child off of settling methods that are not independent.

Sleep Apnea
Sleep apnea means short cessations of breathing during sleep. These disrupt the sleep very much, so that a child with sleep apnea will usually show symptoms of sleep deprivation. This often happens when the child’s airway is blocked during sleep and he must wake up briefly to breathe. A snoring child will have loud breathing which sometimes stops for a few seconds, followed by a louder snore which occurs when the block is cleared. These children often have severely enlarged tonsils and/or adenoids, chronic allergies, or chronic nasal infections with sinus problems. Very obese children (and adults) are prone to sleep apnea.

If the underlying cause cannot be treated medically, the surgical removal of the adenoids will often solve the problem.

Night Terrors
A child will awaken and scream or thrash around. When the parent goes to him, the child is not really awake and does not respond to comforting, often pushing the parent away. This is not a nightmare. During dream sleep, the body is very still. This is a partial wakening. The child is between Stage IV sleep and the next phase, which might be Stage I or REM. His body seems awake, but he is not aware of his surroundings. In this state, the child could get up and walk around or start talking but not be aware. This is a benign condition which stops by itself after five to fifty minutes. If you do nothing, it will be OK, as long the child is kept safe. The child never remembers the episodes. Despite all the screaming, he is not suffering at all. If you waken him, he will wonder why you are bothering him.

There is a way of stopping these terrors if they happen repeatedly. In the beginning of the night, allow the child to fall asleep and sleep for about forty-five minutes. Wake him up fully, and then put him back to sleep. This method interrupts the disturbing cycle of brain wave activity which has developed.

NightmaresNightmares are bad dreams that frighten the child. Unlike night terrors, the child remembers the dream. They happen infrequently and are usually not an ongoing problem. They reflect fears or problems going on in everyday life. Reassurance is all that is usually needed.

Difficulty Falling AsleepEnergy – Children are physiologically programmed to have a lot of energy. They are driven to move all of their muscles to ensure good development of strong muscles and straight bones, as well as strong hearts and efficient lungs. If the day goes by without exercise, there is a buildup of energy that creates a restless feeling. Children need to burn off their energy. If the child’s school day is too sedentary, he will be too pent up to fall asleep. It is essential that children be allowed vigorous exercise as soon as possible at the end of the school day. This means running around, a trip to the park, jumping rope, or some indoor activity that burns energy, like dancing.

This should not be right before bedtime since the exercise makes them alert and mentally active.

Sleep Routines – From an early age, it is advisable to develop a sleep routine to prepare the child for sleep. Brushing teeth, singing songs, reading stories, saying good night with a kiss, is a normal bedtime routine for a child even as early as one year of age. It takes a few minutes, but it is worth the time, since the parent and the child both benefit.

Caffeine – Most kids will fall asleep as soon as their heads hit the pillow. There are some kids, however, who lie awake for a long time and sleep does not come. This is a miserable problem which should be taken seriously.

If your child is having difficulty falling asleep, make sure he is not getting any caffeine in his daily diet. Caffeine is a drug which can take up to 24 hours to wash out of the brain, so eating it ,even early in the morning is not acceptable. Watch out for the hidden caffeine in food:

• All coffee-flavored foods, including yogurt, candies, and ice cream, contain caffeine. Some cakes (including chocolate cakes) have coffee in the recipe.
• Dark Chocolates are very full of a caffeine-related compound, and eating them can be like drinking coffee.
• Soft drinks, such as certain orange sodas, Mountain Dew, and all colas (unless labeled caffeine-free) contain large amounts of caffeine.
• All non-herbal tea and all tea products have caffeine. Snapple, Tealicious, Nestea, and iced tea mixes all have caffeine unless they specifically say they have no caffeine.

If you are sure there is no chemical reason for the child’s difficulty falling asleep, there are other possibilities to be considered.

Naps – It is important that afternoon naps not be too late in the day. If the child falls asleep in the late afternoon, try to wake him up in about 20 to 30 minutes. He will be irritable for a few minutes, but he will soon come around, and then he can make it to bedtime without falling apart. A longer nap can disturb his night sleep.

Fears and Anxieties – Nighttime brings darkness, and an anxious child might feel frightened to be alone. Mild fears might be exaggerated by the child to gain more time with the parents. If the fears do not seem as strong as the child claims (most parents can tell), firm but gentle reassurance will usually suffice. If the child is truly terrified, there may be something troubling him. It is very helpful to try to get the child to express what exactly he feels is so frightening. This will sometimes reveal that he heard about someone who died recently, or that someone has threatened him. These disturbances do not always come out the first time you ask him, so keep the door of communication open by telling him repeatedly that he should always tell his Mother or Father about his troubling thoughts and feelings so you can help him. If the extreme fear of bedtime does not resolve after a few weeks, a professional child psychologist should be consulted.

Melatonin – If there are no fears, but the child simply cannot fall asleep, he may be lacking in a secretion of the pineal gland which is near the brain. This substance, called melatonin, is the signal to the brain that sleep is approaching. It sets the sleep clock in motion. This is why it is often used to treat the sleep disturbance that is associated with jet lag.

Melatonin is secreted mostly in response to darkness. An interesting observation has been made. Babies who are taken outside during the afternoon hours and are exposed to bright daylight seem to sleep better at night. Their brains are able to respond better to the onset of darkness. It is thought that melatonin is strongly suppressed during the daytime light exposure, and then it is secreted generously when darkness comes.

Many pediatricians, including me, recommend synthetic melatonin to be given as a supplement at bedtime for children who have difficulty falling asleep. A recently published paper also showed that melatonin is very useful in children with brain damage who cannot sleep. Melatonin can be purchased in a health food store or drug store, and is safe to be used any time it is needed. There have been no toxicities reported, even in long term use. The usual dose is 1, change this to little 1/2 milligrams at bed time, to be given with a calcium-rich food like milk or cheese or supplement like Tums. The dose can be as high as 6 milligrams, but most kids do well on doses between 1 ½ to 3 milligrams.

Occasionally, the antihistamine Benadryl can be used to help a child fall asleep, if recommended by your pediatrician. Most kids get a little drowsy from Benadryl, but some get agitated instead. If this happens, do not try it again. It will wear off in four hours.

The important thing to note is that a child who does not sleep sufficiently can have problems during the day. Whether it is sleep apnea or other issues, a sleepless child is often irritable, intolerant, miserable, and restless. Rather than sleepy, he may be hyperactive and have difficulty concentrating. The whole personality is affected. Sleep is a critical factor in overall good health. Always take the matter seriously if a child cannot sleep. Consult your doctor if you feel that there is a real problem.